ICD-10-CM. Gastroenterology. Specialty Code Set Training. Module 1

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1 ICD-10-CM Specialty Code Set Training Gastroenterology 2014 Module 1

2 Disclaimer This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course. AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s) bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers interpretations may vary from those in this program. Finally, the law, applicable regulations, payers instructions, interpretations, enforcement, etc., may change at any time in any particular area. This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within. Clinical Examples Used in this Book AAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members. To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah CODE (2633), Fax , Printed. All rights reserved. CPC, CPC-H, CPC-P, CPMA, CPCO, and CPPM are trademarks of AAPC. ii ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

3 ICD-10 Experts Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and Training Contents Specificity in Code Selection Neoplasms Upper GI Neoplasms Neoplasms of the Pancreas Cirrhosis of Liver Foreign Bodies Code Extensions Symptoms and Signs AAPC. All rights reserved. iii

4 One of the reasons that we are transitioning to ICD-10-CM is the increased specificity to enable conditions to be clearly indicated. Care must be taken to ensure that providers and coders understand where the code set has expanded to be able to capture that information and denote it on a claim. Specificity issues include laterality, time parameters, site, and expansion of certain conditions under ICD-10-CM. Neoplasms ICD-10-CM offers greater specificity in this subcategory. When coding for neoplasms the choices include: Morphology Site Malignant Benign Primary Secondary Carcinoma in Situ Uncertain behavior Unspecified Laterality Contributing Factors Exposure to environmental tobacco smoke Exposure to tobacco smoke in the perinatal period History of tobacco use Occupational exposure to environmental tobacco smoke Colorectal Neoplasms Colorectal cancer starts in the lining of the bowel. If left untreated, it can grow into the muscle layers underneath, and then through the bowel wall. Most begin as a small growth on the bowel wall: a colorectal polyp or adenoma. These growths are usually benign, but some develop into cancer over time AAPC. All rights reserved. 1

5 Source: AAPC Many physicians document by centimeters on procedures involving the colon. Anus 0 4 cm Rectum 4 16 cm Upper third is covered by peritoneum; the lower third is not and it is also called the rectal ampulla Rectosigmoid cm From the anal verge Sigmoid cm Loop extending distally from border of left posterior major psoas muscle Descending cm Approximately cm long and located behind the peritoneum Transverse cm Lies anteriorly in the abdomen and attached to the gastrocolic ligament Ascending cm Approximately cm long and located behind the peritoneum Cecum 150 cm Approximately 6x9 cm pouch covered with peritoneum In ICD-10-CM the codes for neoplasms are site specific. 2 ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

C18.0 Malignant neoplasm of cecum C18.1 Malignant neoplasm of appendix C18.2 Malignant neoplasm of ascending colon C18.3 Malignant neoplasm of hepatic flexure C18.

6 C18.0 Malignant neoplasm of cecum C18.1 Malignant neoplasm of appendix C18.2 Malignant neoplasm of ascending colon C18.3 Malignant neoplasm of hepatic flexure C18.4 Malignant neoplasm of transverse colon C18.5 Malignant neoplasm of splenic flexure C18.6 Malignant neoplasm of descending colon C18.7 Malignant neoplasm of sigmoid colon C18.8 Malignant neoplasm of overlapping sites of colon C18.9 Malignant neoplasm of colon, unspecified A benign neoplasm of the colon (adenomatous colon polyp) is coded to the subcategory of D12 according to the sites listed above as defined by the fourth character. During a screening colonoscopy, Dr. Smith removes a polyp from the descending colon. Pathology reports confirm it is benign. ICD-10-CM: D12.4 Benign neoplasm of descending colon A polyp of the colon that is not considered adenomatous (D12.6), inflammatory (K51.4), or polyposis of colon (D12.6) and has no further definition is simply coded K63.5 for polyp of colon. Adenomatous polyps may develop into cancer over time and they are coded in the neoplasm chapter. Inflammatory and simple benign polyps are coded in the diseases of the digestive system chapter. Upper GI Neoplasms Cancers of the esophagus, stomach, and small intestine are referred to as upper gastrointestinal tract (UGI) cancers. These cancers represent the second most common site of digestive system cancers. Source: AAPC There are two main types of esophageal cancer. The majority of cancers in the upper two thirds of the esophagus are squamous cell carcinomas. Adenocarcinomas start in glandular tissues and usually occur in the lower esophagus near the stomach AAPC. All rights reserved. 3

7 Stomach or gastric cancers can develop in any part of the stomach and may spread throughout the stomach and other organs. Most stomach cancers are adenocarcinomas that arise in the glandular cells. Cancer of the small intestine is rare and the majority of these are adenocarcinomas and most commonly start in the duodenum, jejunum, and the small intestine near the stomach. Adenocarcinoma of the small intestine is usually associated with Crohn s disease and celiac disease as well as familial polyposis syndromes. Leiomyosarcomas most often occur in the ileum and some are carcinoid tumors. Neoplasms of the Pancreas Pancreas cancer can occur in the cells lining the ducts or in the islet cells. The pancreas is a digestive organ and has two main jobs in the body: produce juices that help digest food and to produce hormones, such as insulin and glucagon that help control blood sugar levels. These hormones help the body use and store the energy it gets from food. The pancreas is a thin pear-shaped gland, lying on its side, which is about 6 inches long. The pancreas is located in the upper abdomen surrounded by the stomach small intestine, liver, spleen, and gallbladder. It has three areas: Head wider end Body middle section Tail narrow end Pancreatic ductal adenocarcinoma accounts for 90 percent of cancers of the pancreas. Pancreatic cancer is the fourth and fifth most common cancer in men and women, respectively. It accounts for more than 30,000 new cases and 20,000 cancer-related deaths each year. Most patients are older than 60 years. It has the lowest five-year survival of any cancer, reflecting late diagnosis and low resection rates. Pancreatic cancer is aggressive. Of pancreatic cancers, 60 percent develop in the pancreatic head and 40 percent develop in the body and tail. Symptoms include abdominal pain, anorexia, weight loss, and jaundice. The American Cancer Society reports that only about 23 percent of patients with cancer of the exocrine pancreas are still living one year after diagnosis. Only about 4 percent are still living five years after being diagnosed. 4 ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

Source: AAPC Malignant neoplasms of the pancreas are assigned codes from the category C25 and the location of the neoplasm is essential for proper assignment. Codes are broken down as: C25.

8 Source: AAPC Malignant neoplasms of the pancreas are assigned codes from the category C25 and the location of the neoplasm is essential for proper assignment. Codes are broken down as: C25.0 Malignant neoplasm of head of pancreas C25.1 Malignant neoplasm of body of pancreas C25.2 Malignant neoplasm of tail of pancreas C25.3 Malignant neoplasm of pancreatic duct C25.4 Malignant neoplasm of endocrine pancreas C25.7 Malignant neoplasm of other parts of pancreas C25.8 Malignant neoplasm of overlapping sites of pancreas C25.9 Malignant neoplasm of pancreas, unspecified A patient was diagnosed with operable adenocarcinoma of the pancreas tail. C25.2 Malignant neoplasm of tail of pancreas 2013 AAPC. All rights reserved. 5

9 The patient is a 62-year-old male with long time alcohol dependence who recently presented with an obstructive jaundice and concerns for a pancreatic mass. He underwent an endoscopic ultrasound yesterday revealing a mass in the body of the pancreas. Cytology revealed malignant cells. C25.1 Malignant neoplasm of body of pancreas F10.20 Alcohol dependence, uncomplicated CODING TIP: When coding for malignant neoplasm of the pancreas there is an instructional note that states: Use additional code to identify: alcohol abuse and dependence (F10.-). Cirrhosis of Liver The liver is the largest solid organ in the body. The liver is located on the right side and is made up of two large sections, right and left lobes. The liver is protected by the rib cage. The liver has a wide range of functions: Make proteins Help fight infections Cleans the blood Helps digest food Stores a form of sugar that your body uses for energy Liver Gallbladder Duodenum Stomach Copyright OptumInsight. All rights reserved Cirrhosis is a slow progressing scarring of the liver where healthy tissue is replaced by scar tissue which prevents the liver from functioning properly. The most common causes of cirrhosis of the liver are fatty liver, hepatitis, and alcohol abuse. According to the National Institutes of Health, cirrhosis is the 12th leading cause of death by disease. ICD-10-CM offers greater specificity in this subcategory. When coding for the cirrhosis of the liver the choices include: K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver Cryptogenic cirrhosis (of liver) 6 ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

10 Macronodular cirrhosis (of liver) Micronodular cirrhoisis (of liver) Mixed type cirrhosis (of liver) Portal cirrhosis (of liver) Postnecrotic cirrhosis (of liver) A 63-year-old man presents with progressive weakness, abdominal discomfort, and jaundice. He has no history of, or risk factors for viral hepatitis and he has no history of drinking alcohol. Ultrasound showed hepatosplenomegaly and a small amount of ascities. A liver biopsy showed micronodular cirrhosis. K74.69 Other cirrhoisis of liver When coding for the alcoholic cirrhosis of the liver the choices include: K70.30 Alcoholic cirrhosis of liver without ascities K70.31 Alcoholic cirrhosis of liver with ascities A 52-year-old man presents to the GI office with new onset jaundice and ascities. He has been a heavy drinker of vodka for 18 years and is dependent. K70.31 Alcoholic cirrhosis of liver with ascities F10.20 Alcohol dependence, uncomplicated CODING TIP When coding for alcoholic cirrhosis of the liver there is an instructional note that states: Use additional code to identify: alcohol abuse and dependence (F10.-). Foreign Bodies A foreign body in the esophagus and GI tract is any object that does not belong in the esophagus and GI tract that becomes stuck there. There are many causes of foreign bodies in the esophagus and GI tract with a number of factors such as age, complications, and injury. Esophagus The largest cause of foreign bodies in the esophagus is food impactions. In ICD-10-CM the codes for foreign body of esophagus are coded by type of contents and the complication it is causing. T Unspecified foreign body in esophagus causing compression of trachea T Unspecified foreign body in esophagus causing other injury 2013 AAPC. All rights reserved. 7

11 T Gastric contents in esophagus causing compression of trachea T Gastric contents in esophagus causing other injury T Food in esophagus causing compression of trachea T Food in esophagus causing other injury T Other foreign object in esophagus causing compression of trachea T Other foreign object in esophagus causing other injury A 68-year-old man presents to the ED with increasing shortness of breath. The patient was eating dinner when he felt like he had a piece of meat stuck. He has been coughing to try to get it unstuck but it is still there and now the shortness of breath is getting worse. GI was consulted and after testing was completed it is determined the patient is experiencing compression of his trachea due to food in his esophagus. The patient will have endoscopy to remove the foreign body. T18.120A Food in esophagus causing compression of trachea, initial encounter Gastrointestinal (GI) Tract The gastrointestinal tract is the tubular passage of mucous membrane and muscle extending about 8.3 meters from the mouth to anus. In ICD-10-CM the codes for foreign body in gastrointestinal (GI) tract are coded by site. T18.0- Foreign body in mouth T18.2- Foreign body in stomach T18.3- Foreign body in small intestine T18.4- Foreign body in colon T18.5- Foreign body in anus and rectum T18.8- Foreign body in other parts of alimentary tract T18.9- Foreign body of alimentary tract, part unspecified Code Extensions Codes for foreign bodies are located in chapter 19, Injury, Poising and Certain Other Consequences of External Causes. Most categories in chapter 19 have seventh character extensions that are required for each applicable code. For foreign bodies there are three extensions: A, initial encounter, D, subsequent encounter and S, sequela. 8 ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

12 CODING TIP Remember, the seventh character must always be the seventh character in the data field. If a code that requires a seventh character is not six characters in length, a placeholder X must be used to fill in the empty characters. Extension A initial encounter is used while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. CODING TIP Don t latch on to the word initial as this could hinder your appropriate selection, instead keep in mind the words active treatment as identified in the guidelines. Extension D subsequent encounter is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external of internal fixation device, medication adjustment, other aftercare, and follow-up visits following injury treatment. The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the seventh character D (subsequent encounter). Extension S, sequela, is for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The S extension identifies the injury responsible for the sequela. The specific type of sequela (eg, scar) is sequenced first, followed by the injury code. Symptoms and Signs Use of Symptom Codes Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Symptoms and Signs Involving the Digestive System and Abdomen (R10-R19) ICD-10-CM offers greater specificity in this subcategory. When coding for the abdomen the choices include: Type Pain Tenderness Rebound tenderness Swelling Mass and lump Rigidity 2013 AAPC. All rights reserved. 9

13 Laterality Site Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant Epigastric Periumbilic Generalized A patient visited his general surgeon with complaints of epigastric pain, the physician documents epigastric rebound abdominal tenderness and orders testing. R Epigastric rebound abdominal tenderness Dysphagia Dysphagia is difficulty swallowing. It usually is a sign of a problem with the throat or esophagus. ICD-10-CM offers greater specificity in this subcategory. When coding for dysphagia the choices include: R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophageal phase R13.19 Other dysphagia CODING TIP When coding for dysphagia there is an instructional note that states: Code first, if applicable, dysphagia following cerebrovascular disease (I69. With final characters -91) Dyspepsia and Other Specified Disorders of Function of Stomach Dyspepsia is a discomfort in the upper abdomen or chest that may be described as gas, a feeling of fullness, gnawing, or burning. ICD-10-CM offers greater specificity in this subcategory. When coding for dyspepsia and other specified disorders of function of the stomach the choices include: R10.13 Epigastric pain (dyspepsia) K30 Functional dyspepsia 10 ICD-10-CM Specialty Code Set Training Gastroenterology 2013 AAPC. All rights reserved.

14 K31.0 Acute dilatation of stomach K31.1 Adult hypertrophic pyloric stenosis K31.2 Hourglass stricture and stenosis of stomach K31.3 Pylorospasm, not elsewhere classified K31.4 Gastric diverticulum K31.5 Obstruction of duodenum K31.6 Fistula of stomach and duodenum K31.7 Polyp of stomach and duodenum K Angiodysplasia of stomach and duodenum with bleeding K Angiodysplasia of stomach and duodenum without bleeding K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum K31.83 Achlorhydria K31.84 Gastroparesis K31.89 Other disorders of stomach and duodenum 2013 AAPC. All rights reserved. 11

ICD-10 Documentation Training: Urgent Coding for Emergent Conditions

ICD-10 Documentation Training: Urgent Coding for Emergent Conditions Presented by Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC AAPC ICD-10-CM/PCS Training Expert Copyright 2014 AAPC Disclaimer This